LISA A . CICO, MSN, NPUPSTATE MEDICAL UNIVERSITYBREAST & ENDOCRINE SURGERYCOORDINATOR THYROID CANCER

PROGRAMSURGICAL COORDINATOR BREAST

CANCER PROGRAM

THYROIDNODULES

OBJECTIVES

Describe tools / diagnostic testing for assessment of the patient with a thyroid nodule(s)

*Utilize national guidelines developed for patients with thyroid nodules

*Describe some of the common symptoms of patients with thyroid nodules

Comprehensive review of current diagnostic tools and imaging to assess thyroid nodules

Review American Thyroid Association, & National Comprehensive Cancer Network Guidelines for patients who develop thyroid nodules

Review common symptoms of patients with thyroid nodule

OBJECTIVES Identify which patients can safely be followed by PCP

*Describe imaging/diagnostic modalities for following the patient with thyroid nodules

*Identify those patients requiring referral to specialty

*Identify which specialty to make an appropriate referral based on diagnostic, objective and symptomatic findings

 

Obtaining appropriate imaging/diagnostic testing, and frequency

Overview of ultrasonographic thyroid terminology

Overview of Betheseda thyroid nodule pathology terminology

Obtaining appropriate personal and family history

Identify what patients require referral and to endocrine or surgery?

Briefly discuss appropriate follow up for the patient with thyroid cancer

Definition of Thyroid Nodule

“A discrete lesion within the thyroid gland that is palpably and/or ultrasonographically distinct from surrounding thyroid parenchyma”

*ATA Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer (2006 & 2009 Task Force)

0

10

20

30

40

50

60

10 20 30 40 50 60 70

PalpationAutopsyUltrasound

Prevalence

Rallison et al. JAMA 1975

Hogan et al. J Surg Res 2009

“How was this nodule found?”

Palpation with a physical examIncidental finding on diagnostic work upSelf detectionSurveillance Work up for symptoms of

hyper/hypothyroidism

How was found is it clinically relevant?

Physical Examination of Thyroid Gland

Visual inspectionPalpation of thyroid, neck nodes, and

supraclavicular nodesFixed, mobile, soft, tender?Reflexes why?HR, BP, weight

Symptoms

Usually NONE!!Occasionally painful, quick onset (cyst)Difficulty swallowing Hoarseness OR change in voiceShortness of breath (or difficulty swallowing)

usually while supine OR hands raised over head (Pemberton’s Sign)

Choking sensation hyper/hypo thyroid

Nodules Hyper/Hypo thyroid

Difficulty swallowing

Globus sensation

Choking sensation

Hyper-functioning nodule

Hashimoto’s

Symptoms?

History Physical Findings

Head & neck irradiation

Whole body irradiation

Nuclear falloutFamily history of

thyroid malignancyHeredity

Rapid growthHoarsenessCervical

/supraclavicular lymphadenopathy

Fixation of nodule or gland

> 4 cmSolitary

Pertinent History & PE in Evaluation of TNs

Differential Diagnosis

Multinodular GoiterHashimoto’s ThyroiditisCancerLymphoma

Solitary Thyroid NoduleSubsternal Goiter

COWDEN’S SYNDROMEFAMILIAL POLYPOSIS

CARNEY COMPLEXMEN 2

WERNER SYNDROMETHYROID MALIGNANCY

Family Historyof

Hereditary Diseases

Substernal Goiters

Short neckStocky build

Usually incidental finding by CXR or CTMany times treated unsuccessfully for

asthma

Ultrasound: The Gold Standard

Anyone found to have,OR is suspected of having a nodule evaluate by ultrasound!!

BENIGN

CHARACTERISTICS

Pure cystic (relatively rare)

Spongiform appearance in >50% of nodule volume (aggregration of multiple microcystic components)

Multiple (?)

Septated cyst

BENIGN

Cyst

BENIGN

US (a, transverse; b, longitudinal) scans in 51-year-old woman show 2.4-cm well-defined mixed-echoic hypoechoic nodule (arrows) in right lobe of thyroid gland. Initial cytologic result was adenomatous hyperplasia, confirmed after 11 months at repeat aspiration

BENIGN

ULTRASOUND CHARACTERISTIC

CONSIDERATIONS

High-risk history: History of thyroid cancer in one or more first degree relatives; history of external beam radiation as a child; exposure to ionizing radiation in childhood or adolescence; prior hemithyroidectomy with discovery of thyroid cancer, 18FDG avidity on PET scanning; MEN2/FMTC-associated RET protooncogene mutation, calcitonin >100 pg/mL. MEN, multiple endocrine neoplasia; FMTC, familial medullary thyroid cancer.

Suspicious features: microcalcifications; hypoechoic; increased nodular vascularity; infiltrative margins; taller than wide on transverse view.

FNA cytology may be obtained from the abnormal lymph node in lieu of the thyroid nodule.

Sonographic monitoring without biopsy may be an acceptable alternative

SUSPICIOUS

CHARACTERISTICS

Hypo-echogenicity compared to normal thyroid parenchyma

Increased intra-nodular vascularityIrregular infiltrative marginsPresence of micro-calcificationsAbsent haloShape taller than width in

transverse dimensionNodules > 4 cmSolitaryDifficulty swallowing

ATA Guidelines 2009

Hypoechoic

Suspicious

Increased vascularity

Suspicious

Increased vascularity

SUSPICIOUS

CalcificationsPoorly defined, irregular margins

SUSPICIOUS

Solid

SUSPICIOUS

Multiple Thyroid Nodules

FNA what nodule??> 1 cmSuspicious featuresDominant / largest one

Palpation? Ultrasound?

What nodule(s) do you FNA?

What nodule(s) do you FNA?

FNA of Palpable Nodule

TN with suppressed TSH

UPTAKE SCAN to assess autonomous nodule

Compare to U/S what is the correlation with Uptake

FNA consider in non - functioning or isofunctioning with suspicious features

FNA

Only GOLD standard for proof of malignancy without surgical pathology

False Negative False Positive

false-negative rate of up to 5% with FNA which may be even higher with nodules >4 cm

??

FNA

< 1 cm > 1 cm

NO

ATA Guidelines 2009

NO

Is Size a Predictor of Malignancy?

FNA Results

NondiagnosticBenignAtypia of Undetermined Significance (AUS)Suspicious for a Follicular

Neoplasm/Follicular NeoplasmSuspicious for MalignancyMalignant

Bethesda System for Reporting Thyroid Cytopathology

Diagnostic Category Risk of Malignancy (%)

Usual management

Nondiagnostic or Unsatisfactory

Repeat FNA with ultrasound guidance

Benign 0-3 Clinical Follow up with ultrasound 6 months

Atypia of Undetermined significance or Follicular lesion of Undetermined significance

5-15 Repeat FNA 3 months; if same, then lobectomy

Follicular Neoplasm or suspicious for Follicular neoplasm

15-30 Surgical Lobectomy

Suspicious for Malignancy

60-75 Near total thyroidectomy or surgical lobectomy

Malignant 97-99 Near total thyroidectomy

Lab Work

TSHFree T4

TPO in suspected thyroiditis

TG tumor marker in PTC, FTC, HTC

Calcitonin suspected MTC or in follow up of MTC

TSH

Free T4

T4

T3

Free T3

TPO

Thyroglobulin (TG)

Calcitonin

Thyroid nodule

FNA

Benign

Exam/Sonogram 6-18

months

No Change

Repeat in 3-5 yrs

20% increase in diameter in

> 2 dimensions (>2mm) or

volume increase >

50%

Re-aspirate Thyroid Nodule

Nodule sonographic or clinical features Recommended nodule threshold size for FNA

High-risk historya    

Nodule WITH suspicious sonographic featuresb >5mm Recommendation A

Nodule WITHOUT suspicious sonographic featuresb >5mm Recommendation I

Abnormal cervical lymph nodes Allc Recommendation A

Microcalcifications present in nodule ≥1cm Recommendation B

Solid nodule    

AND hypoechoic >1cm Recommendation B

AND iso- or hyperechoic ≥1–1.5 cm Recommendation C

Mixed cystic–solid nodule    

WITH any suspicious ultrasound featuresb ≥1.5–2.0 cm Recommendation B

WITHOUT suspicious ultrasound features ≥2.0 cm  Recommendation C

Spongiform nodule ≥2.0 cmd Recommendation C

Purely cystic nodule FNA not indicatede Recommendation E

TABLE 3. SONOGRAPHIC AND CLINICAL FEATURES OF THYROID NODULES AND RECOMMENDATIONS FOR FNA 

RAI Uptake Scan

ONLY IN HYPERTHYROID

Cold Nodule - 10% incidence of being CA

From 2005 to 2009, incidence rates increased by 5.6% per year in men and 7.0% per year in women, making thyroid cancer the fastest increasing cancer in both men and women

Most common endocrine cancer

Thyroid Cancers

Projected Cases of Thyroid Cancer

60, 220 new cases are estimated for 2013 45, 310 female 14, 910 male

1,850 deaths projected for 2013 1,040 female 810 male Death rate 0.5 per 100,000 in both male and

females

AGE & INCIDENCE AMCERICAN CANCER SOCIETY / NCCN/ SEER

Diagnosed at a younger age then most adult cancers Median age at diagnosis was 50 years from 2005-

2009 2 out of 3 cases are < 55 years old

Thyroid cancer in the pediatric population Pediatric Incidence 2.0 per 1 million in children <15

yrs and 17.6 per 1 million in children 15-19 yrs 2% occur in children and teens

TREATMENT

FOR

THYROID

CANCER

Surgery

Radioactive Iodine Ablation

Levothyroxine

Monitor with WBS / ultrasound

CHILDREN&

PREGNANT WOMEN

WHEN DO YOU OPERATE???

Complications of Thyroid Surgery

Recurrent laryngeal nerve injury

Hypo parathyroidism

Bleeding

Infection

Parathyroid glands

COMPLICATIONS OF SURGERY

OR case

COMPLICATIONS OF THYROID SURGERY

Surgery and TC

Low MORTALITY

Thyroid cancers LOW Mortality!! Rod Stewart, Julie Andrews, Joe Piscopo

Always exceptions to the rules : Roger Ebert, Supreme Court Justice

Reinquist

Should be LOW MORBIDITY too!!

IF surgery is required, always refer to someone who does at least > 50 / year

NO drains!!

NO RR tracks!!

Dermabond is ulgy on the neck, and often opens a bit…

Summary

Refer to Endocrin0logy or Surgery

Children Pregant women Nodules > 1 cm with

suspicious features Compressive symptoms HT with globus symptoms

ULTRASOUND!! Even if already had CT, carotid doppler, etc

Can safely follow with ultrasound

Nodule < 1 cm Stable nodules with no

changeRepeat in 6 months x 2, then

annually

Monitor TFTs with U/S

ENDOCRINE SURGERY

Suspected/known abnormal TFTs with TNs

Pregnant

If FNA needed

Children

If suspect surgery is indictated

Endocrine OR Surgery?

QUESTIONS?

Thank You